GOOD AFTERNOON

Timing of Class II treatment: Skeletal changes comparing 1-phase and 2-phase treatment Calogero Dolce,a Susan P. Etall

(Am J Orthod Dentofacial Orthop 2007;132:481-9)

 The best timing for treatment of Class II malocclusion has been controversial. The question is whether early treatment, which is initiated during the mixed dentition, is more effective and efficient than treatment started in the permanent dentition. Can early treatment provide superior skeletal, dental, or esthetic results?

 Reviews of Class II treatment studies before 1989 concluded that, because of their inadequate designs, it was not yet known whether early treatment provided enough benefits to justify it. Recent data have become available from 2 randomized clinical trials that addressed this question.

 Irrespective of which appliance was used, both reduced the severity of the Class II skeletal discrepancy at the end of phase 1.

 Results from the end of phase 2 treatment in these studies are beginning to be reported. It appears that many differences between treatment groups that are evident at the end of phase 1 are no longer present by the end of phase 2.

 Subjects who receive treatment in 2 phases, with the first aimed at orthopedic correction in the mixed dentition and the second detailing the permanent dentition, do not have significant skeletal or dental differences from those who receive 1 phase of treatment in the permanent dentition.

 In this study, we report on the skeletal changes from phases 1 and 2, using the complete cephalometric data set from 1 clinical trial.

MATERIAL AND METHODS

The study was a prospective, randomized clinical trial with 2 treatment groups and an observation group. During phase 1, the subjects were treated with either a bionator or headgear/biteplane. An equal number of subjects were followed in the observation group. Assignment into a group was based on molar class severity, mandibular plane angle, need for preparatory treatment, race, and sex

 After phase 1 treatment and a 12-month observation period, all subjects received the most appropriate phase 2 finishing orthodontic treatment, usually involving full fixed orthodontic appliances.

The inclusion criteria consisted of overbite overjet, 3 deciduous molars, Class II molar relationship, all permanent first molars, less than 3 permanent canines or premolars, and good general health..

The exclusion criteria included

periodontal problems or dental decay, unwillingness to be randomly assigned to a treatment group, and failure to sign informed consent

 Each subject for phase 1 treatment was randomized into 1 of 3 groups: bionator, headgear/biteplane, and observation. Phase 1 treatment lasted until 2 project orthodontists independently agreed that a bilateral Class I molar relationship was achieved or 2 years had elapsed from the start of treatment.

 After phase 1 treatment, half of the subjects in the bionator and headgear/biteplane groups were randomly assigned to 6 months of retention. This consisted of wearing the bionator only at night or wearing the headgear/biteplane every other night. This was followed by 6 months of no retention;

 Phase 2 treatment was determined as follows:: In general, each patient was reviewed by an average of 4 orthodontists, selected from the American Association of Orthodontists directory. Based on their responses, a consensus treatment plan was formulated for phase 2 treatment. Of the 261 subjects, 20% of the observation, 12% of the headgear/biteplane, and 8% of the bionator groups had some premolars extracted

 During phase 2 treatment, headgear was used more often (42%) in the observation group. All lateral cephalograms were traced and digitized; 60 points were identified. Only the following points were used for analysis: nasion (N), sella (S), A-point, B-point, orbitale, porion, anterior nasal spine posterior nasal spine, gonion, and gnathion

Statistical analysis
Descriptive statistics were used to examine the data. Treatment group were assessed by using chisquare tests for categorical variables and analysis of variance (ANOVA) for continuous variables. Linear regression models were used to examine the impact of a standard set of covariates (age at baseline, treatment group, sex, initial cephalometric values, and initial molar class severity) on cephalometric measures at the end of phase 1 and the end of treatment

 All analyses were made with software (SAS, Cary, NC; Insightful Corporation, Seattle, Wash). A P value less than 0.05 was considered statistically significant.

SNA angle decreased during phase 1 treatment in the headgear/biteplane group but relapsed to its original value during retention before the start of phase 2 treatment.
In the bionator and observation groups, SNA angle increased during phase 1 and until the start of phase 2,and finally SNA angle in these groups decreased during phase 2 treatment

Greatest increase in SNB angle was in the bionator group .The observation group had greater changes in SNB angle than the headgear/biteplane group Between the end of phase 1 and the beginning of phase 2, SNB angle increased significantly in the headgear/biteplane group, so that it became similar to the observation group. During phase 2 treatment, there were few changes in SNB angle in all treatment groups.

 ANB angle decreased in both the bionator and the headgear/biteplane groups The observation group changed little until phase 2 treatment. At the end of phase 2, there was little difference in ANB angle between the 3 groups.

 In the observation and bionator groups, SN-MP angle decreased until phase 2 treatment. Phase 1 treatment resulted in an increase in SN-MP angle in the headgear/biteplane group it relapsed before phase 2 treatment. Phase 2 treatment resulted in a slight increase in SN-MP angle in all 3groups.

DISCUSSION
The following possibilities have been suggested as possible effects of functional appliances on mandibular growth: (1) increased beyond its genetic potential; (2) accelerated when there is an increase in the growth rate during treatment, followed by a period of slow growth, thereby achieving the expected growth; or (3) anterior mandibular positioning with adaptation as further growth occurs. Our data suggest that there is no growth beyond the genetic potential, thus eliminating the first possibility.

CONCLUSIONS 1. Phase 1 treatment with either a bionator or headgear/ biteplane results in a decrease in ANB angle. 2. Headgear/biteplane results in an increase in SNMP at the end of phase 1. 3. Early intervention had no effect on the skeletal pattern at the end of all treatment compared with treatment in 1 phase at adolescence. 4. Using linear regression analysis, we demonstrated that treatment group had no effect on the final cephalometric values

Proffit WR, Tulloch JF. Pre adolescent ClassII problems: treat now or wait? Am J Orthod Dento facial Orthop 2002;121:560-2. The purpose of this study was to determine the effects of early treatment on the maxillary dental arches in children with mixed dentition Results: The data revealed that the growth pattern did not change with the treatment The early treatment with occipital headgear was effective in moving maxillary teeth distally and retracting incisors, improving the jaw relationship and favoring the second phase of the orthodontic treatment when necessary.

Influences on the out come of early treatment for Class2 malocclusion

American Journal of Orthodontics and Dentofacial Orthopedics 1997;111:533-42 1. There is great variation in response to early Class II growth modification treatment. 2. Approximately 75% of children undergoing early treatment with either headgear or a modified bionator, experience a favorable or highly favorable reduction in skeletal discrepancy. 3. This response to early treatment is significantly different from the growth experienced by similar but untreated children with Class II malocclusion.

Comparison of arch dimension changes in 1-phase vs 2-phase treatment of Class II malocclusion American Journal of Orthodontics and Dentofacial Orthopedic July 2009;136:65-74

This study showed that, although early phase 1 treatment was useful in gaining space in the maxillary arch or minimizing space loss in the mandibular arch ,over those who had no early treatment, there were no differences after phase 2 therapy when full orthodontic appliances were removed. In the end, all subjects had similar changes in arch dimensions.

Am J Orthod Dentofacial Orthop. 2002 Jan;121(1):31-7. Efficiency of early and late Class II Division 1 treatment. The aim of this study was to assess the efficiency of early and late Class II Division 1 treatment in the mixed and permanent dentition. Based on the results of this investigation, we concluded that treatment of Class II Division 1 malocclusions is more efficient in the permanent dentition (late treatment) than it is in the mixed dentition (early treatment).

PREVENTIVE ORTHODONTICS

By
Md.Mazhar Ahmed 1st year MDS Department of orthodontics

Graber (1966) defined preventive orthodontics as the action taken to preserve the integrity of what appears to be normal occlusion at a specific time Profit and Ackerman (1980)defined as prevention of potential interference with occlusal development

 Preventive orthodontics means a dynamic, ever constant vigilance, a routine, a discipline for both dentist and patients.
It requires a continuing long-term approach and is not a one shot service. Without this, the complex timetable of growth, development, tissue differentiation, resorption, eruption which are all under the influence of continuous functional forces, cannot be assured.

 Dental neglect in the primary dentition is the principal cause of malocclusion in the permanent dentition. Early, regular and satisfactory dental care will help in maintaining the primary teeth in healthy condition until the time for their normal exfoliation.

Preventive procedures
Parental counseling
prenatal postnatal

Caries control Space maintenance Extraction of deciduous teeth Treatment of abnormal frenal attachments Treatment of locked permanent first molars Abnormal oral musculature related habits

Parents should be educated regarding Increase in food intake to meet the special physiological changes in the body to support the growth of the foetus and facilitate normal labour. Dental development of their child Dental disease process Oral hygiene measures appropriate for infants

Education of parents

 Expecting mother should be educated on proper nursing and care of the child.
conventional

In case the child is being bottle-fed, the mother is advised to use physiologic nipple and not the conventional nipple.

phys

 As the child grows, parents should be educated regarding the need for maintaining good oral hygiene.
In infants small gauze is used over the ridge of top and bottom jaws for cleaning Proper brushing techniques and brushing habits to be explained and evaluated periodically.

Fones method of brushing is preferred in children.

Fluoride application and dental checkup every 6 months

Caries control procedures:

Diet and oral hygiene Maintenance Regular Checkup Fluoride applications Prophylactic odontomy Pit and fissure sealants. Restorative procedures like silver amalgam, Glass Ionomers, Cermets, Stainless steel crown. Immunization

Diet and Oral hygiene maintenance

Balanced diet
which contains varieties of food, in such quantity and proportion that the need for energy ,amino acids, vitamins, fats, carbohydrates and other nutrients is adequately met for maintaining health. The cariogenic potential of food depends on many variables such as presence of fermentable sugar sucrose ability to be retained by teeth. ability to form acids. ability to dissolve enamel.

 The solid foods containing sucrose are more cariogenic than liquid foods.

The frequency in time of ingestion of foods are also important. The sucrose containing food becomes more dangerous if it is eaten more frequent.
The patient should be aided in identification of those foods which are likely to cause oral diseases.

The 3 to 6 yrs olds require parental assistance to achieve effective plaque removal.

Parents should be instructed to brush for the child at least once a day.
Bedtime is the ideal time to establish this routine because the salivary flow rate slows during sleep Additional brushings may be performed by the child.

Parents need to remain active in supervising the home care practices of 6-12 yrs old

Regular check-up:
The parents should bring their child for his/her first dental visit early at least by the time the baby is 6 months of age. Frequency of recall visits have to be decided according to the individual needs. Usually a 3 monthly recall checkup is advised to monitor oral hygiene status. Half yearly visit to the dentist should be routine.

Care of Deciduous dentition

Deciduous teeth act as natural space maintainers until the developing permanent teeth are ready to erupt into oral cavity. All efforts are taken to prevent early loss of deciduous teeth.

Simple preventive procedures such as proper and timely application of fluoride topically/ pit and fissure sealant application help in preventing caries. More complex treatment procedures to prevent the natural space maintainer includes pulp therapy (pulpotomy, pulpectomy ) and stainless steel crown.

 Caries involving proximal surface of deciduous teeth if not restored early may lead to loss of arch length into that space. Caries can be detected by clinical and Radiographic examination.

Bitewing Radiograph proves to be of great help in detecting proximal caries.

Once detected, proper restoration of affected teeth should be undertaken immediately to prevent loss of arch length.

 Restoration should restore the mesio-distal dimension of tooth, but should not be over/under extended allowing drift of contiguous teeth or promote food impaction.
Contact size and position should also be correct.

Re establishment of proper inclined plane relationship with proper anatomic carving will be esthetic and results in normal function and stability of occlusion.

PIT AND FISSURE SEALANT

Fissure sealants are defined whereby pits and fissures that occur principally on the occlusal surfaces of the molar and premolar teeth are occluded by application of fluid materials, which are the then polymerized.

Classification Mitchell and Gordon (1990) Polymerization methods a. Self activation (mixing two components) b. Light activation - First generation: U.V Light - Second generation: Self cure - Third generation: Visible light - Fourth generation: Fluoride releasing
Resin Systems BIS-GMA Urethane acrylate Filled and unfilled Clear or tined

Indications
Newly erupted both primary molars and permanent bicuspids and molars with complete recession of pericoronal operculum and with open and/or sticky grooves and fissures.

Stained pits and fissures with minimum decalcification.

The tooth in question should have erupted less than 4 years ago.

Contraindications

Individual with no previous caries experience pit and fissures,monitor if the individual and the teeth are not at risk. Radiographic or clinical evidence of caries on the proximal surface of the tooth should not be sealed. Wide and self-cleansable pit and fissures.
Tooth that can not be isolated of partially erupted tooth. Pit and fissures that have remained carious free for 4 years or longer.

Fluoride application
Knutsons Technique Sodium fluoride 2% (3,7,11,13)

- Weekly internals 4 times

- After prophylaxis 3min
Personal attention of parents towards child with respect to dental care is a must.

The attitudes of parents and child towards dental health and dental care are very much influenced by the attitude of the dentist towards preservation of primary dentition and preventive outlook.

FLOURIDE VARNISH
Bifluoride 12(2.71% NaF, 2.92% CaF) Technique Do the through prophylaxis and dry the teeth. Drop the varnish onto the brush or foam pellet.

Paint the varnish thinly first on the lower arch and then on upper arch starting from the proximal surfaces.
Semiannual Application With correct application and proper mouth hygiene varnish remains in place of several days. During this time fluorides act on the treated surface.

Prophylactic odontomy
Caries occurs frequently in the pit and fissures of posterior teeth. As a preventive procedure the pit and fissure may be minimally prepared and restored before visible attack by caries.

Immunization
Immunization with Streptococcus mutans should induce an immune response which might prevent the dental caries in following ways : It will prevent ability of the microorganisms to colonize on to the tooth surfaces.

It can alter the pattern of polysaccharide metabolism by the bacteria and thereby reduces adhering capacity on to the tooth surfaces. Oral administration or subcutaneous injection of killed Streptococcus mutans can induce the formation of specific IgA, IgG, IgM in the blood.

Various new approaches have been tried out in order to overcome the existing disadvantages. Active immunization 1) Synthetic peptides 2) Coupling with cholera toxin subunits 3) Fusing with salmonella 4) Liposomes

Passive immunization
1) Monoclonal antibodies 2) Egg-yolk antibodies 3) Transgenic plants

Indicators of future Orthodontic Problems:

Aberrant resorptive pattern Altered eruption cycle of permanent teeth Contingency of extraction
A visual examination of the patient will quickly reveal a gross malocclusion, in which there is an anterior open bite, excessive overbite and overjet, cross-bite, basal malrelationship and other problems.

 A large percentage of class I malocclusions exist because of what happens during the critical developmental years, with most of the activity below the surface.

So,not only a visual dental examination, but a complete and accurate radiographic examination should be made soon after the first visit.

 Deciduous canines and second deciduous molars are particularly prone to aberrant resorption patterns. In an ideal sequence, right and left deciduous incisors should be lost at about the same time, deciduous lateral incisors should be lost at about the same time, all canines should be lost within a short period.

Contingency of extraction As a rule of Thumb, the shedding of the deciduous dentition should be kept on schedule by extracting the tooth or teeth on one side of the arch, when they have been lost through natural process on the other side. Should not wait longer than 3 months for nature to do the job, particularly when there is radiographic evidence of abnormal resorption Which would otherwise lead to Malocclusion.

Effects of premature loss of primary teeth

Oral health and functions Supra eruption of opposing teeth Psychological effect on child and parent Position of permanent teeth.

Primary dentition is essential for growth of jaws, for normal function and eventually for normal position and occlusion of permanent teeth and so premature loss of primary tooth is to be avoided.

 Parents usually accept loss of anterior teeth after 6years of age, but when lost at an early age, some parents are concerned by appearance of remaining dentition.
Attitudes of parents and child towards dental health and care is largely influenced by attitude of dentist towards preservation of primary dentition. Any suggestion that the primary dentition is important is reflected is a positive awareness and motivation towards dental care in minds of parent and child.

Sequence of eruption and clinical significance:

According to MOYERS normal sequence of eruption provides the highest percentage of normal occlusion Eruption in
Maxillary arch - 6124537

Mandibular arch - 6124357

Abnormal order of arrival may permit shifting the teeth, with resultant space loss.

of

Change in the sequence of eruption is a much more reliable sign of a disturbance in normal development than generalized decay or acceleration. The more a tooth deviates from its expected position in the sequence,the greater the likelihood of some problem.

An asymmetry in rate of eruption on the two sides of dental arch is a frequent variation. When this happens, there is lack of space to accommodate the erupting teeth on one side compared to the other.
As a general rule, if permanent tooth on one side has erupted but its counter part has not, within three months, a radiograph should be taken to investigate the cause of the problem.

SPACE MAINTAINANCE
Maintenance of arch length during the primary, mixed and early permanent dentition is of great significance for the normal development of future occlusion. Loss of arch length has been related mainly with migration of teeth following early loss of primary teeth. 18th Century Fauchard reported it 19th Century Hunter 20th Century Willet, Seward,and Davey

Causes of space loss

Trauma Interproximal caries in primary molars Ectopic eruption of first perm molars Delayed eruption Ankylosis of primary molars. Congenital absence of permanent teeth Macrodontia can cause arch length deficiency

 Space maintaining is utilizing an appliance to preserve space without necessarily an awareness of the dynamics of the situation.
The preferable approach for space maintenance is to evaluate the space available, whether the space is sufficient for eruption of the succedaneous teeth or regaining space is necessary.

Classification of space maintainers: According to Hitchcock:

Removable or fixed or semi fixed With bands or without bands Functional or non functional Active or passive Certain combinations of above.

According to Raymond C.Thurow:

Removable Complete arch
Lingual arch
Extra oral anchorage

Individual tooth.

According to Hinrichsen
Fixed space maintainers:
Class I 1.Non functional types
- Bar type - Loop type 2. Functional type - Pontic type - Lingual arch type

class II
- Cantilever type
- Distal shoe - B and E loop

Removable space maintainers Removable

Non functional acrylic plate Functional acrylic plate with teeth

Active acrylic plate with clasps, springs Passive - acrylic plate with clasps.

Fixed appliances Band and loop Crown and loop Band and bar Distal shoe Lingual arch Nance palatal arch Transpalatal arch. Semi Fixed Removable arch wire with molar bands

Indications of space maintainers

If space after premature loss of deciduous teeth shows signs of closing. If use of space maintainer will aid in or make the future orthodontic treatment less involved. If the need for treatment of malocclusion at a later date is not indicated.

 Even though space maintenance is not necessary in case of anterior tooth loss, a functional space maintenance or partial denture should be given as tooth loss affects speech, induce abnormal tongue habits which leads to malocclusion .

Contra indications of space maintainers

If radiograph of extraction region shows that 1/3rd of the root of succedaneous tooth is already calcified. When the space left by the prematurely lost primary tooth is less than the space needed for the permanent successor as indicated radiographically. If the space shows no signs of closing

Advantages of Removable type of Space Maintainers.

They are easy to clean and permit maintenance of proper oral hygiene It maintains and restores the vertical dimension. It can be worn part time allowing circulation of the blood t soft tissues. They serve other important functions like aesthetic,mastication,phonetics

 Dental checkup for caries detection can be undertaken easily. They stimulate eruption of permanent teeth Band construction is not necessary

Room can be made for permanent teeth to erupt without changing the appliance

 They prevent development of tongue thrust habit into the extraction space.
More than one tooth can be replaced.

Being tissue-borne, they impose less stress on remaining teeth.

Easier to fabricate, less chair time.

 When there is general lack of sufficient arch length and where space maintainer would further complicate existing malocclusion.
When succedaneous tooth is absent. When well developed occlusion and cuspal inter digitations or over eruption of opposing tooth prevent space closing.

Disadvantages:
Patient may not wear it, patient compliance in
6year age group and uncooperative children It may be lost or broken by the patient. It may restrict lateral growth of the jaws if clasps incorporated are 3is poor.

They may cause irritation of the underlying soft tissues.

Fixed Space Maintainers;

Band and Loop Band and Bar Crown and Bar Trans palatal arch Lingual arch Pin and tube space maintainers. Bonded space maintainers.

Modifications of Band and Loop Space Maintainer

Crown and loop

Band and loop Extended band and loop Bonded band and loop

Nances palatal arch space maintainers

 Advantages of Fixed Space Maintainers:

They do not interrupt with passive eruption of abutment teeth. Jaw growth not hampered Succedaneous permanent teeth are free to erupt in oral cavity. Can be used in uncooperative patients.

Disadvantages:
Elaborate instrumentation with expert skill is needed It may result in decalcification of tooth material under the bands Supra eruption of opposing teeth can take place if pontics are not used. If pontics are used, it can interfere with Vertical eruption of abutment tooth and may prevent eruption of replacing permanent teeth, if patient fails to report.

Indications: Unilateral loss of primary first molar before or after the eruption of permanent first molars. Bilateral loss of single primary molar before eruption of permanent incisors. When second primary molar is lost after the eruption of first permanent molar. Sometimes it is given in cases of premature loss of primary canines.

BAND AND LOOP SPACE MAINTAINER

 Usually Band- loop space maintainers is not indicated to preserve the space created by two adjacent primary molars. The lengthy loop created in these situations is more susceptible to the forces of mastication.
Advantages: It is an effective space maintainer for unilateral loss of single tooth in buccal segments. Economical Construction is simple

 Takes little chairside time, especially if preformed bands are used. It adjusts easily to accommodate the changing dentition. Disadvantages: Requires constant supervision. Like any other fixed maintainers, decalcification under the bands is a problem. It will not prevent the continued eruption of the opposing teeth.

LINGUAL ARCH:
The lingual arch is the most effective appliance for space maintenance in posterior region and minor tooth movement in the lower arch. The lingual arch space maintainer consists of two bands cemented to the 1st permanent molars or sometimes 2nd deciduous molars, which are joined by a SS wire butting against four incisors.

Usually indicated to preserve the spaces created by multiple loss of primary molars when there is no loss of space in the arch.

 The use of lingual arch is a good preventive measure, since it helps in maintaining the arch perimeter by preventing both mesi drifting of the molar teeth and also lingual collapse of the anterior teeth.
Spurs that is Projections of wire, may be used as stoppers distal to anterior teeth to prevent their migration distally in the arch. These help in maintaining symmetry of centre lines, cases of unilateral tooth loss.

especially in

Advantages: Causes little inconvenience to patient Less bulky them removable acrylic space maintainers. Less conspicuous than other space maintainers Serves as a space maintenance for more than one succedaneous tooth in the arch. Prevents arch collapse Prevents mesial migration of banded tooth.

Disadvantages
Prolonged use of orthodontic bands decalcification of the tooth.

Arch wire may become embedded into the soft tissue. This seems to occur more often in patients with poor oral hygiene.
Wire may become distorted by masticatory forces and move teeth into undesirable positions. Appliance should be removed every year and inspected for damage and further usefulness, recemented after topical fluoride treatment

Transpalatal Arch :

Recommended for stabilizing the maxillary first permanent molars. Best Indication for transpalatal arch is when one side of the arch is intact, and several primary teeth on the othe side are missing. Also indicated when primary molars are lost bilaterally. Appliance is designed to prevent the molars from rotating around the palatal roots ,which is the first movement resulting in loss of space in the arch perimeter. The transpalatal arch runs directly across the palatal vault connecting the permanent first molars, avoiding contact with the soft tissue

Advantages:
No food lodgment Simple design No inflammatory changes in palate

Disadvantages:
If given in case of bilateral missing deciduous molar, cannot prevent drifting of abutment teeth. If not passive ,unexpected vertical and transverse movement of the permanent molars can occur.

Distal Shoe Appliance:

Eruption guiding appliance Intra alveolar appliance One of the early designs of distal space maintainers was cast Gold or Willet distal shoe Now rarely used because of increased cost, difficulties in tooth preparation, and more complicated fabrication procedures. The distal shoe appliance is used to maintain the space of a primary second molar that has been lost before the eruption of the permanent first molar.

 Normally,the distal surface of the 2nd primary molar provides a guide for the unerupted 1st permanent molars, when the 2nd primary molar is removed prior to the eruption f the first permanent molar, the Distal Shoe appliance provides greater control of the path of eruption of the unerupted tooth and prevents undesirable mesial migration.

Indications:
When 2nd primary molar is extracted or lost before the eruption of first permanent molar.

Contraindications:
Poor oral hygiene Medically compromised patients like patients with congenital heart disease, juvenile diabetics, Rheumatic fever, immunosupression If several teeth are missing in same quadrant as there lack of abutment. Lack of patient cooperation

Nance palatal holding arch

Indicated in premature loss of first deciduous molar. Advantages:
Economical Allows growth transversely in the inter-canine areas.

Disadvantages:
Requires more clinical skill Palatal button may cause food accumulation; causes inflammation.

Abnormal frenal attachments

Abnormalities of the maxillary labial frenum are associated with a midline diastema .

At birth frenum is attached to the alveolar ridge with fibers running into the incisive papilla. The teeth erupts and as alveolar bone is deposited,the frenum attachment migrates superiorly with the alveolar ridge.

Fibers may persist between the maxillary central incisors and in the V shaped intermaxillary suture , attaching to the outer layer of the periosteum and connective tissue of the suture.

Faustin weber noted that diastema may be due to other factors, the possible causative factors : Microdontia,Macrognathia,Supernumerary teeth,Peg laterals,Missing lateral incisors. Habits such as thumb sucking, tongue thrusting & midline pathologies.

Oral Habits in Children and their Management

These habits bring about harmful unbalanced pressures to bear upon the immature, highly malleable alveolar ridges, the potential changes in position of teeth, and occlusions, which may become decidedly abnormal if these habits are continued for a long time. . Boucher a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic

Prevention starts with proper nursing, proper choice of physiologically designed nursing nipple & pacifier to enhance the normal function and deglutitional maturation

Proper kinesthetic, neuromuscular gratificational activity at this time may ell prevent abnormal finger, lip and tongue deforming action.
Constant tongue thrust into an edentulous area make cause an open bite that remains in the permanent dentition. An unfavorable oral condition to frequently stimulates a child to place his fingers in his mouth- this can well lead to finger sucking or nail biting.

THUMB SUCKING
Definition Repeated and forceful sucking of thumb with associated strong buccal and lip contractions.(Moyers) Defines digit sucking as placement of thumb or one or more fingers in varying depths into the mouth(Gellin) Most children would stop digit sucking by the age of three to four years. But an acute increase in childs level of stress and anxiety due to some underlying psychological or emotional disturbances can account for continuation of digit sucking habit, with conversion of an empty habit into a meaningful stress reducing response.

Causative factors:
Parents occupation Working mother Number of siblings Order of birth of the child Social adjustment and stress Feeding practice Age of the child

Effects on maxilla

Effects on mandible

- proclination of maxillary incisors - increased maxillary arch length - anterior placement of apical base - increased SNA - increase in clinical crown length of anteriors - counter clock wise rotation of occl.plane - decreased SN to ANS-PNS angle - decreased palatal arch width - atypical root resorption in primary central incisors - trauma to maxillary central incisors - proclination or reteroclination of the mandibular incisors - increased intermolar distance - distal position of point B

Effects on interarch relationship

- maxillary and mandibular incisal angle - increased over jet - decreased over bite - posterior cross bite - uni-bilateral class-II occlusion

Effect on lip placement and function Effect on tongue placement and function Other effects

- incompetence lips - lower lip function under the maxillary incisors - tongue thrust - lip to tongue resting position - lowered tongue position
- thumb deformity - speech defects, lisping

Treatment
Psychological therapy Reminder therapy Extra oral approaches Intra oral approaches Mechanotherapy Blue glass Quad helix

Tongue trusting:
Definition:

Schneider 1982: tongue thrust is forward placement of the tongue between the anterior teeth and against the lower lip during swallowing

Tongue trusting:

Maxilla

- Tipping of the palatal plane -Proclination of maxillary anteriors resulting in increase in over jet - Generalized spacing between the teeth - Teeth may be mesially inclined - or all parameters may be norm -Retroclination or Proclination of mandibular teeth depending on the type of growth -Generalized spacing between the teeth -Teeth may be mesially tilted - or all parameters may be normal

Mandible

Inter arch

- Anterior or posterior open bite depending on the posture of the tongue - Posterior cross bite - lack of interdigitation of the posterior teeth - Or all the parameters may be normal

Facial form lips Tongue

- Convex profile - Increased LAFH

- Short upper lip/normal upper lip - Hyperactive mentalis/ normal - Enlarged - Forwardly placed - Normal position
-Tongue thrust children are more likely to have various speech disorders, such as sibilant distortions, lisping problems in articulation of s, n, i, d, l, th, z, v sounds

Speech

Definition:

Sassouni (1971) defined mouth breathing as habitual respiration through the mouth instead of the nose. Merle (1980) suggested the term oro-nasal breathing instead of mouth breathing. F.M. Chacker defined mouth breathing as the prolonged or continued exposure of the tissues of the anterior area of the mouth to the drying effects of the inspired air.

PREVENTION MYOFUNCTIONAL APPLIANCES Oral myofunctional therapy has been shown to be effective in correcting oral myofunctional disorders such as tongue thrust swallow, improper tongue and mouth resting posture, improper use of muscles of the mouth, tongue, and lips for chewing and swallowing, and late thumb/finger sucking habits.

Lip habit
It may involve either of the lips , with a higher predominance of lower lip Definition Habits involving manipulation of the lips and perioral structures are termed as lip habits. Classification Wetting the lips with the tongue Pulling the lips into the mouth between the teeth (schneider1982)

Treatment

Correction of malocclusion Treating the primary habit Appliance therapy Lip bumper

Nail biting
Nail biting is one of the most commonest habit in children and adults. It is a sign of internal tension Etiology Emotional problem Effects Dental Crowding, rotation, attrition of incisal edges Effects on the nails Inflammation of the nail beds

Conclusion
Prevention of malocclusion and the success of minor and/or major orthodontic intervention in a developing malocclusion depend upon the diagnostic skill and a clinical ability to reverse the process of the dentitions maldevelopment. The concept of prevention is based on the belief that some, if not many, minor dental developmental problems, in the younger age group become major orthodontic needs. Early attention to many, if not all problems in dental development of children can be helpful in reducing the severity of malocclusion

Interceptive orthodontics

123

Contents
INTRODUCTION DEFINITIONS OF INTERCEPTIVE ORTHODONTICS VARIOUS INTERCEPTIVE ORTHODONTIC PROCEDURES SERIAL EXTRACTION CORRECTION OF DEVELOPING CROSS BITE CONTROL OF ABNORMAL HABITS SPACE REGAINING
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Introduction
orthodontic treatment is popularly regarded as springs,plates, and braces. There is however, much in orthodontic treatment that depends not much upon appliances In general practice children can be seen from a very early age.

An inherited malocclusion may not be preventable, but much can be

done to correct a developing malocclusion or atleast to alleviate some of the sequelae.
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 The goals of orthodontic care in the primary dentition should be aimed at

either intervention in the conditions that predispose one to develop a malocclusion in the permanent dentition or monitoring conditions that are better treated later(Nagan and Fields, 1955). According to the third National Health and Nutritional Examination Survey, crowding and irregularity remain a consistent problem for children. The goal of early treatment is to correct existing or developing skeletal, dentoalveolar and muscular imbalances to improve the orofacial

environment before the eruption of the permanent dentition is complete.

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 early treatment is often a two phased treatment.

Phase-1 treatment typically begins when the child is about 8 years or younger and lasts about 6-12 months. This is followed by intermittent observation of transition from the mixed to the permanent dentition. Phase-2 treatment usually with the fixed orthodontic appliances on permanent teeth, begins 6-9 months before the eruption of the second molars.

127

 However, the single phased treatments have gained popularity in which the early treatment is initiated in the late mixed dentition, just before the loss of the deciduous second molars, and is followed immediately by banding and bonding of the permanent teeth. Reduction in the total treatment time and better control of the Leeway spaces in the transitional dentition are some of the advantages.

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Definitions
The American Association of Orthodontists (1969) defined interceptive orthodontics as that phase of science and art of orthodontics employed to recognize and eliminate the potential irregularities and malpositions in the developing dentofacial complex. Profitt and Ackermen (1980) defined interceptive orthodontics as the elimination of the existing interferences with the key factors involved in the development of the dentition.

Sheety N

defines interceptive orthodontics as early intervention in the

developing dentition to minimize the developing malocclusion or eliminate the potential factors interfering with the normal occlusion.
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Various procedures
Serial extraction Correction of developing crossbite Control of abnormal habits Space regaining Interception of skeletal malrelation Removal of soft tissue or bony barriers to enable eruption of teeth

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SERIAL EXTRACTIONS
The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence (Dewel 1969).

Serial extraction can be defined as the correctly timed, planned

removal of certain deciduous and permanent teeth in mixed dentition cases with dento-alveolar disproportion in order to:

Alleviate crowding of incisor teeth.

Allow unerupted teeth to guide themselves into improved positions (canines in particular).
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Lessen (or eliminate) the period of active appliance therapy.

 It is a sequential plan of premature removal of one or more deciduous teeth in order to improve alignment of succedeous permanent teeth and finally removal of permanent teeth to

maintain the proper ratio between tooth size and available

bone. Thus it is one of the positive interceptive orthodontic procedure generally applied in most discrepancy cases where supporting bone is less than the total tooth material.
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Historical development
Paisson was the first person who pointed the extraction procedure in order to improve the irregular alignment and crowding of teeth. Bunon in 1743, in his Essay on the Diseases of the teeth proposed the removal of deciduous teeth to achieve a better alignment of permanent teeth. Nance presented clinics on his technique of progressive extraction in 1940 and has been called as the father of serial extraction philosophy in the United States.
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 Kjellgren in 1940 termed this extraction procedure as planned or progressive extraction procedure of teeth. Hotz named the same procedure as Guidance of eruption. When a dentist sees a child 5 or 6 years of age with all the deciduous teeth present in a slightly crowded state or with no spaces between them, he can predict, with a fair degree of certainity, that there will not

be enough space in the jaws to accommodate all the permanent teeth in

their proper alignment (Lysell 1960)
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 Nance (1940), Mooress (1963), Dewel (1954), and others have pointed out, after the eruption of the first permanent molars at 6 years of age, there is probably no increase in the distance from the mesial aspect of

the first molar on one side around the arch to the mesial aspect of the
first molar on the opposite side

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 Premature loss of deciduous teeth. Lingual eruption of lateral incisors.

Indications

Arch-length deficiency and tooth size discrepancies. Unilateral deciduous canine loss and shift to the same side. Abnormal eruption direction and eruption sequence.

Flaring of incisors.
Ectopic eruption of mandibular first deciduous molar. Abnormal resorption of II deciduous molar. Ankylosis. Labial stripping, or gingival recession, usually of lower incisor.

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limitations
According to Dewel (1967), the most serious side effect is tendency of bite to close following loss of posterior teeth. premolars may fail to reach their normal occlusal level. Lip fullness is not a reliable criterion for extraction in early mixed dentition & the early removal of premolars is likely to

cause a concave profile.

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Contraindications
Mild to moderate crowding Deep or open bites Severe Class II, III of dental/Skeletal origin Cleft lip and palate Spaced dentition Anodontia / oligodontia, Midline diastemia

138

Advantages
Psychological trauma can be avoided by treatment Reduces the duration of the multi banded treatment Physiological treatment as it involves the guidance of teeth into normal positions making use of physiological forces Better oral hygiene More stable results

139

Disadvantages
Patient co-operation is needed Risk of arch length reduction is present Requires proper professional and clinical judgment

As extraction spaces are created the patient may develop the tendency of
tongue thrusting. Spacing may develop between canine and second premolar. Complication of serial extraction when premature eruption of permanent canines occur, the first premolars are impacted between the canines and the second premolars
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Tweed,s method
At approximately 8 years all deciduous molars are extracted. It is preferable to maintain in deciduous canines to retard eruption of permanent canines. 4-10 months of following extraction of deciduous Ist molars, the Ist premolar will have erupted upto gingival level. Do not extract till the crown arc, above the alveolar bone. Extraction of 1st premolar and deciduous canines should be done 4-6 months prior to eruption of permanent canines when they erupt they
141

migrate posteriorly into good position.

142

Dewels Method:

CD4
143

Moyer's method
Stage I (Extraction of all deciduous lateral incisors). It helps in alignment of central incisors. Stage II (Extraction of all deciduous canines after 7-8 months). It helps in alignment of lateral incisors. Stage III (Extraction of all deciduous first molars). It stimulates eruption of all first premolars.

Stage IV (Extraction of all first premolars after 7-8 months). It

provides space for canines and stimulates eruption of canines.
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Enucleation
Enucleation has been defined as surgical removal of unerupted teeth usually premolar to minimize crowding. Most common disadvantage are loss of buccal or lingual cortical plates of bone or clefting associated with incomplete closure of extracted site.

145

Advantages
Fewer visits, therefore decrease in trauma and emotional disturbance. In severe maxillary anterior crowding and excessive protrusion, enucleation provides space for retraction of 1 and 2 proper eruption of 3. In crowded high angle cases, enucleation especially of 5 causes mesial migration of posterior segment.

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Space regaining
This is a procedure used for recovering the space which once existed in the arch. Space regaining procedures should be limited to reestablishing 3-5mm or less space in the localized area. Space is easier to regain in the maxillary arch than in the mandibular arch, because of Increased anchorage for removable appliance afforded by the palatal

vault.
The possibility for use of extra-oral force like head gear.
147

Selection Criteria For Space Regainer

The selection of the space regaining appliance is dependent on whether Tipping Translation Rotation or combination of these movements.

148

MAXILLARY SPACE REGAINING

PALATAL BAR REMOVABLE DISTALIZING PLATE

HELICAL FINGER SPRING WITH REMOVABLE APPLIANCE

LINGUAL ARCH WITH SEGMENTAL ARCH WIRE EXTRA ORAL FORCE VIA FACE BOW EXTRA ORAL FORCE VIA HEADGEAR REPELLING MAGNETS MODULE ORTHODONTIC APPLIANCE LOOP COMBINATION HOOK APPLIANCE THE K-LOOP MOLAR DISTALIZING APPLIANCE
149

Mandibular space regainers

ACTIVE LINGUAL ARCH LIP BUMPER MANDIBULAR PENDEX SPRING APPLIANCE EXPANSION SCREW APPLIANCE BONDED LINGUAL ARCH

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Gerber space regainer

Tube and wire U assembly are not welded. An eyelet may be welded to the flattened part of

the tube next to the band; weldable tube stops

are soldered on wire portion and open coil spring sections are cut to fit over wire between stops and ends of U tube. The length of the push coil springs is established by placing the bond tube wire assembly in the mouth, extending the wire to

the desire length, in contact with the mesial

tooth, and measuring the distance between the tube stops on the wire and the end of the U tube.
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Open coil spring :

An edge wise twin bracket is aligned and welded to the buccal surface of the abutment band adjacent to the space before the lingual arch portion of the appliance is cemented into place.

A band is also fitted to the first permanent molar to be tipped distally and a buccal tube is properly aligned and welded to the band before it is cemented into place.

A 0.016 inch round or a 0.016 x 0.016inch rectangular wire is selected so that it will slide freely in the buccal tube but it can

also be fixed to the bracket with a ligature wire.

The wire is cut to the desired length and adjusted to the alignment of teeth by making smooth, gentle bends if necessary.

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 A section of open coil spring (0.009 x 0.020 inch) approximately 2 mm longer than the space between the bracket and the tube is placed around the wire, and the entire assembly is fixed in position.

Bilateral stability and anchorage may be provided with a soldered

lingual arch As this space opens, the wire and spring are replaced with a longer

section at approximately 4 weeks intervals until the desired position is

attained.
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Hotz lingual arch

This is appropriate in a situation where first molar

has shifted mesially, but the premolar or cuspid

has not drifted distally. It is advantageous to use removable type of space

maintainer since it facilitates removal for frequent

activation.

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Lip bumper/ plumper

Mostly used bilaterally & can also be used unilaterally.

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Removable appliances
RECURVED HELICAL SPRING REGAINER

It is an appliance that is similar to Hawleys

appliance consisting of an Adams clasp and a labial bow for retention and a recurved helical

spring regainer which is used for regaining the

space lost due to mesially tipped molar. The recurved helical spring is activated by

opening the coil.

The wire components are embedded in the acrylic plate.
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SLING SHOT REGAINER YOKE SPACE-

SLIDING REGAINER

EXPANSION SCREW

157

Crossbites
Graber, defined cross bite as a condition where one or more teeth may be abnormally malposed buccally or lingually or labially with reference to the opposing tooth or teeth.

SCISSOR BITE: - Total maxillary buccal or mandibular lingual

cross bite with mandibular dentition completely contained with in the maxillary dentition in habitual occlusion.

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Classification
Based on their location Anterior cross bite Single tooth Segmental Total Skeletal Posterior cross bite Unilateral Bilateral Based on Nature of Cross Bite Skeletal Dental Functional
159

Anterior crossbite
Anterior cross bite is defined as a malocclusion resulting from the lingual position of the maxillary anterior teeth in relationship with the mandibular anterior teeth. This is a condition where reverse overjet is seen in mandibular anterior teeth overlapping the maxillary anterior .

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Anterior crossbite
Anterior cross bite of one or more of the permanent incisors should be

treated in the mixed dentition state or as soon as it is discovered.

Etiology:

A labially positioned Supernumerary tooth.

Fracture to an anterior primary tooth An arch length deficiency Persistence of a primary tooth

Presence of habits like thumb sucking and mouth breathing

Patients who suffer from cleft palate (collapsed arch) Sagittal discrepancies of the jaws
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Classification
Individual: Due to a malposed incisor or canine displaced towards palate.

Total: Caused by an anterior displacement of the mandible.

Skeletal: Due to an over growth of the mandible, retarded maxilla or a combination of these. B)Simple anterior dental CROSSBITE Functional anterior CROSSBITE

True skeletal anterior CROSSBITE

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Treatment
TONGUE BLADE THERAPY
It can be used successfully in a developing single tooth anterior CROSS BITE where

sufficient space is present for bringing the

tooth out. This technique is useful when child is co-

operative and have proper encouragement

and guidance at home. A tongue blade is a flat wooden stick
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similar to an ice cream stick.

 Mc Donald stated that tongue blade therapy uses the chin as a fulcrum and exert pressure on the tooth toward the labial side. Graber stated that the mandibular incisal margin serving as a fulcrum and the oral portion of the tongue blade should be rotated upward and forward to engage the lingual surface of the lingually malposed tooth. The patient is advised to bite with a constant pressure on the wood incline and at the same time to exert a slight but constant pressure with his hand on the blade so as to prevent blade displacement.

The proper use of the tongue blade for a 1 or 2 hr/day for 10 to 14 days is
usually sufficient to deflect the lingually erupting maxillary incisor ACROSS THE FENCE into a proper relationship.
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catalan's appliance/ lower anterior inclined plane

Introduced by CATLAN, 150 yr back.

In no instance appliance should be left longer than

six weeks. If properly constructed it can correct a CROSS BITE in a matter of days
INDICATION

Normal or excessive overbite and adequate space in the arch to bring the incisor into correct A P relationship with the opposing mandibular incisor

used only in cases where CROSS BITE is due to palatally displaced maxillary incisor.
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 CONTRAINDICATION
When CROSS BITE is due to true mandibular prognathism. If there is an end to end over bite or an open bite

ADVANTAGES
Ease of fabrication Rapidity of correction, using functional and muscles forces. Lack of soreness or looseness of the teeth during movement.

Rarity of relapse

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 DISADVTANGES
Patient has problems in speech during the therapy Strong dietary restrictions: soft and liquid for several days.

If used for long time (>6 wks) lead to open bite (anterior)and TMJ
problem. Possibility of the appliance becoming loose and requiring recementation because of the strong occlusal forces upon it.

Imperfect alignment of the malposed tooth when the appliance is removed. The dentist must rely on autonomous adjustment for the balance of correction.

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 COMPOSITE INCLINES CAST INCLINED INCLINED CROWNS BANDED INCLINE

168

Hawley type appliance with Zspring

Used to correct 1 or 2 maxillary teeth.

Indicated only when adequate space is present .

In case of deep bite the spring must be given along with a posterior bite plane to help in jumping the bite.

Acrylic Hawley type appliance is made with spring pressing against lingual aspect of the incisors.

The spring is activated 1.5 to 2mm to provide 1 mm of tooth movement / month.

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Functional crossbite:
OCCLUSAL EQUILIBRATION
Correction of a pseudo class III anterior CROSS BITE may require only the removal of premature tooth contact by incisal grinding of the maxillary and mandibular incisors.

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SKELETAL ANTERIOR CROSS BITE

DURING GROWTH PERIOD
Retropositioned maxilla must be treated before termination of growth by using a protraction face mask (reverse head gear). These helps in protraction of maxilla and normalizing CROSS BITE. Excessive mandibular growth is

intercepted by reverse activator or F.R III or by use by chin cap with head gear.

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Posterior crossbite
Failure of the two dental arches to occlude normally in lateral relationship, known as lateral or posterior CROSS BITE, may be due to localized problems of tooth position or alveolar growth or to gross disharmony between maxilla and mandible (Moyer) In this condition instead of the mandibular buccal cusps occluding in the central fossae of the maxillary posterior teeth, they occlude buccal to the maxillary buccal cusps .

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classification
A)SEGMENTAL SINGLE TOOTH B)UNILATERAL

BILATERAL
C) BUCCAL NON OCCLUSION: maxillary posteriors occlude entirely on the buccal aspect of the mandibular posteriors , this condition is also called as Scissors Bite LINGUAL NON OCCLUSION: maxillary posteriors occlude entirely on the lingual aspect of the mandibular posteriors
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treatment
FOR SINGLE TOOTH / DENTAL CROSSBITE

Crossbite elastics DENTO ALVEOLAR CONTRACTION and / OR CROSSBITE Removable plate with jackscrew and Adams clasps Soldered W-arch (Porter appliance) Quad helix Coffin spring Arch expansion using fixed appliances

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Skeletal crossbite
Removable appliances Fixed appliances Tooth borne: Isaacson type and Hyrax type Tooth and tissue borne: Derichsweiler type and Hass type Removable appliances :

The treatment during deciduous and early mixed dentition is considered more favourable in producing skeletal effects using removable appliances.

A removable type of rapid maxillary expansion device consists of a split

acrylic plate with a midline screw. The appliance is retained using clasps on the posterior teeth.
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Oral habits
"Habit is defined as an automatic response to a specific situation acquired normally as the result of repetition and learning. At each repetition the act becomes less conscious and if repeated often enough, may enter the realm of unconscious habit. Boucher O.C. defined habit as a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic. When the habit involving the oral cavity becomes fatal, that is when the habit causes defects in orofacial structures it is termed as pernicious oral habit( perinicious fatal)

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classification
1. By Morris and Bohana (1969)
HABIT

EXAMPLE

Non-Pressure Habit Pressure habits Mouth Breathing Sucking Habits Lip sucking Thumb And Nail Biting Needle Holding

DigitSucking Biting Habits

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Earnest Klein(1971)

a. Intentional habits (meaningful) b. Unintentional habits (empty) By Brash a. Purely muscular, e.g. tongue thrusting, lip sucking b. Combined activity of the muscles of jaw, mouth and thumb sucking c. Muscular action combined with introduction of passive object into the mouth, e.g. pencil chewing d. Habits in which muscles of the mouth and jaw take no active part, the effect on the position of the teeth are produced by extraneous pressure, e.g.

abnormal pillowing
E.Functional disturbance, e.g. mouth breathing.
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 Sydney Finn( 1987)

Compulsive Habit : Acquired as a fixation in the child to the extent that he retreats to the practice whenever his security is threatened.

Non Compulsive Habit : Children appear to undergo continuing behavior

modification, which permit them to release certain undesirable habit patterns and form new ones which are socially accepted.

Primary habit and Secondary habits

Secondary habit is a habit that is due to a supplemental problem. Eg. Large tongue
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causes tongue thrusting habit

8. Physiologic and Pathologic habits : Physiologic habits : are those that are required for normal physiologic functioning. eg Nasal respiration, sucking during infancy.

Pathological habits : Habits that are pursued due to pathological reasons

such as adenoids and nasal sepal defects that may lead to mouth breathing 9. Retained and cultivated habits : Retained habits : Those that are carried over from childhood into adulthood.

Cultivated habits : Those cultivated during the socio-active life of an

individual
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 By William James(1923)
Useful habits : Should include all those habits of normal function such as correct tongue position proper respiration and deglutition.

Harmful Habits : All those that exert perverted stress against the teeth and
dental arches. E.g. mouth breathing, tongue thrusting. Normal and abnormal habits Normal habits Abnormal : Those habits that are pursued after their physiological period of

cessation.

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 For the habit to have its effect depends on the frequency, intensity and duration with which the habit is exercised.

Frequency - How often the habit is performed (number of times per day) Intensity - How vigorously is it practiced? Duration - Total number of years/months/weeks/days since the habit is being performed.
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 Points to Consider before treatment of Oral

Habits:
Is the habit normal for that age? e.g. tongue thrusting in an infant is normal
Why has the child acquired the habit? It may be a meaning full or empty habit

Psychological implication for allowing the child to continue the habit

First the psychological problem should be treated then the habit as such Is the habit potentially harmful to the mouth or ; the paraoral structures? Intensity, duration, and frequency are the index of severity of the habit should also be considered
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 Is the habit self correcting, damaging or persisting? e.g. thumb sucking normal in infants and self correcting with the advancing age. 7. What is the correct time of interception for correction? 8. What is the appropriate means of correction the habit? 9.Parental attitude as an important factor

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Thumb sucking habit

According to Gellin "it is the placement of thumb or one or more fingers in varying depths into the mouth". Thumb sucking in infants is common and is meant to meet both psychological and nutritional needs. It is a spontaneous activity that develops soon after birth.

Between birth and 3 months of age, its intensity increases until the age of 7 months and then gradually declines. The habit, if persists beyond may lead to dentofacial changes.
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Classification
1) According to Subtelny (1973) Type A - 50% of the children whole digit is placed inside the mouth with the pad of the thumb pressing over the palate, while at the same time maxillary and mandibular oral contact is present.

Thumb is inserted beyond the first joint, pressing against the palatal
mucosa and alveolar tissue. Lower incisors press against the thumb.
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 Type B -13-24% of the children thumb is placed in the oral cavity and at the same time maxillary and mandibular contact is maintained.

The thumb extends upto the first joint or just anterior to it.
No palatal contact. Contact is present with only the anterior teeth Type C - 16% of the children

thumb is placed into the mouth just beyond the first joint and contacts hard palate and the maxillary incisors, but there is no contact with mandibular

anterior incisors.
Thumb is placed fully into the mouth in contact with the palate as in group I but the lower incisors do not contact the thumb
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 Type D - 6% of the children

only a little portion of the thumb is placed into the mouth. The lower incisors contacted the thumb at the nails

2. According to Cook
1. group: The thumb pushes the palate in a vertical direction and displayed only little buccal wall contractions. 2. group: Strong buccal wall contractions are seen and a negative pressure is created resulting in posterior cross bite. 3. group: Alternate positive and negative pressure is created
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 Normal Thumb Sucking. Abnormal Thumb Sucking Psychological Habitual

189

Dentofacial changes associated with thumb sucking

EFFECTS ON MAXILLA
Proclination of the maxillary incisors Increased maxillary arch length Anterior placement of the apical base of the maxilla Increased clinical crown length of maxillarv incisor
190

primary central incisor Increased trauma to maxillary incisors.

High palatal arch

 Effects On Mandible
Retroclination incisors Retrusion of mandible of

mandibular Effects On Lip Placement

And Function
Development of tongue thrust

Effects

on

interarch Lower tongue position

Hypotonic upper lip Hyperactive lower lip.

relationship
Increased overjet

Decreased overbite Posterior cross bite Anterior open bite.

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Management
1)Preventive Treatment :

Firstly, feed the child whenever he is hungry and let him eat as much as he
wants. Secondly, feed the child the natural way; importance of breast-feeding is primarily psychological and secondarily nutritive. Thirdly, never let the habit to be started the practice must be discontinued at its inception. Use of a dummy / Pacifier Psychological therapy
192

 - hypothesis or Dunlops hypothesis:

Dunlop believed that if a subject can be forced to concentrate on the performance of the act at the time he practice it, he could learn to stop performing the act. Forced purposeful repetition of habit eventually associates with unpleasant reactions and the habit is abandoned. The child could be asked to sit in front of the mirror and asked to observe himself as he indulges in the habit. This procedure is very effective if the child is asked to do the same at a time when he is involved in an enjoyable activity.

4)Chemical Treatment : Quinine, Asafetida, Pepper, Caster oil etc

Femite, Thumb-up, Anti thumb solutions
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Mechanical Therapy or Reminder therapy:

a)Extra-oral approach : Mechanical restraints applied to the hand and digits like splints, adhesive tapes. Thumb guard is the most effective extra-oral appliance for control of the habit. b)Intra-oral approach :

the optimal time for appliance placement is between the ages of 34 years preferably during spring or summer, when the child's health is at its peak and the sucking desires can be sublimated in

outdoor play and social activity.

194

195

 Removable or fixed Palatal crib Oral Screen Quad helix Blue grass appliance : Developed by Bruce S. Haskell (1991). It is a fixed

appliance using a Teflon roller, together

with positive reinforcement.

Used to manage thumb sucking habit in children between 7-13 years of age.
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Modified Blue grass appliance :

This is a modification of the original

appliance with the difference being that this has two rollers of different colors and material instead of one. If the patient tries to suck on his thumb the suction will not be created and his thumb will slip from the rollers thus breaking the act. Thumb-Home concept: This is the most recent concept. In this a small bag is given to the child to tie around his wrist during sleep

and it is explained to the child that just as the child sleeps in his home, the thumb will also sleep in its house and so the child is restrained.
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Tongue thrusting
Tulley (1969) defined tongue thrust as the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue lies interdentally.

Norton and Gellin defined tongue thrust "as a condition in which the
tongue protrudes between the anterior or posterior teeth during swallowing with or without affecting tooth position".

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classification
James S. Brauer and Townssend V. Folt classification of tongue thrusting
Type Type 1 Type 2 Clinical Presentation Non deforming Tongue thrust Deforming Anterior Tongue thrust Subgroup 1 : Anterior open bite Sub group 2 : Associated Procumbency of anterior teeth
199

 Type 3

Deforming lateral tongue thrust Subgroup 1 : Posterior open bite Subgroup 2 : Posterior cross bite

Type 4 thrust open bite procumbency of anterior teeth cross bite

Subgroup 3 : Deep overbite

Deforming Anterior and lateral tongue

Subgroup1 : Anterior and posterior

Subgroup

2:

Associated

Subgroup 3 : Associated posterior

200

Moyer's classification
)Normal infantile swallow 2) Normal mature swallow 3) Simple tongue thrust swallow 4) Complex tongue thrust Swallow

201

Clinical features
Simple Tongue Thrusting Normal tooth contact in posterior region Anterior open bite Contraction of the lips, mentalis muscle and mandibular elevators.

Complex Tongue Thrusting

Generalized open bite

The absence of contraction of lip and oral muscles.
202

Lateral Tongue Thrust

 Other Features Proclination of anterior teeth Anterior open bite Midline diastema Posterior cross bite. Prognosis: Prognosis of Simple tongue thrust habit is excellent and incase of Complex tongue thrust is good whereas in Retained infantile swallow the prognosis

is very poor.

203

Management
Treatment considerations : Tongue thrusting often self corrects by 8 - 9 years of age by the time permanent teeth erupt. If tongue thrusting is associated with other habits then the associated habit must be treated first. Myofunctional therapy : Garliader proposed this method in which the patient can be guided regarding the correct posture of the tongue during swallowing by various exercises like asking the child to place the tip of the tongue in the rugae area for 5 min and then asking him to
204

swallow.

 Orthodontic elastics : The tongue tip is held against the palate using orthodontic elastic of 5/16" and sugarless fruit drop exercise : identifying the spot, This includes

salivating, squeezing

the spot (3S EXERCISE)and swallowing. Using the tongue the spot is identified, the tongue tip is pressed against this spot and the child is asked to swallow keeping the tongue at the same spot.

205

 4. Other exercises : The child is asked to perform a series of exercise such

as whistling, reciting the count from 60 to 69, gargling, yawning etc to tone the respective muscles.

Sub conscious therapy Once the voluntary swallowing pattern is acquired

the patient proceeds to sub conscious therapy in which the patient is asked to place a reminder sign or auto suggestion which requires the patient to give self instructions like repeat 6 times I will swallow correctly all night long"- for 10 nights.

206

 Mechanic

Therapy

Both

fixed

and

removable appliances can be fabricated. The appliance re-educates tongue so that the dorsum of tongue approximates the palatal vault and the tip of the tongue contacts palatal rugae during deglutition. Some of the

appliances that can be used to prevent tongue

thrusting are: 1. Pre orthodontic trainer 2. Modifications of Hawley's appliance 3. Tongue crib 4. Oral Screen
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Mouth breathing habit

Sassouni (1971) defined mouth breathing as habitual respiration through the mouth instead of nose. Classification Given by Finn in 1987 Obstructive: Increased resistance to or complete obstruction of normal airflow through nasal passage. Habitual : persistence of the habit even after elimination of the obstructive

cause.
Anatomical: Short upper lip leads to incompetence of lips and hence mouth breathing.
208

 Appearance: Adenoid face is the characteristic feature of mouth breathers. Lips are held wide apart. There is lack of tone of oral musculature. Upper lip is short and upper teeth seen.. The chin is receded and the face has typical pigeon face appearance. The nose is tipped superiorly. Long narrow face. The face is expression less. The bridge of the nose is flat.

209

Dental & skeletal

Low tongue position. Narrow maxillary arch. Protrusion of maxillary and mandibular incisors. The palatal vault is high. Mandible hangs open in a slack manner. Anterior open bite Increased incidence of caries. Mucus and plaque become more tenacious.
210

Management
The main aspect of management of a mouth-breathing patient is to

treat and eliminate the underlying cause or pathology that has

created the habit.. This should be followed by symptomatic treatment. Other procedures and appliances that can be used are Physical exercise - respiratory exercise Lip exercise Stretching and twisting of upper lip Mechanical Oral Screen/Vestibular Screen Hotz Modification

211

Bruxism
Poselt and Wolffdescribed bruxism as the "clenching or grinding of teeth when not masticating or swallowing". Ramfjord in 1966 defined bruxism as the habitual grinding of teeth when an individual is not chewing or swallowing. Classification : Daytime : Diurnal bruxism / Bruxomania. Can be conscious or subconscious and may occur along with para-functional habits.

Night time bruxism : Nocturnal bruxism. Subconscious grinding of teeth

characterized by rhythmic patterns of masseter

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Etiology
CNS: Could be a manifestation of cortical lesions. E.g. In children cerebral palsy. Psychological factors : A tendency to gnash and grind the teeth has been associated with feeling of anger and aggression or be a manifestation of the inability to express emotions such as anxiety and hate. Occlusal discrepancies Systemic Factors: Magnesium deficiency, chronic abdominal distress, Intestinal parasites. Occupational factors: An over enthusiastic student and compulsive overachievers may also develop the habit
213

Clinical features
Occlusal Trauma : This include tooth ache, mobility mainly in morning. Tooth Structure : Extreme sensitivity due to loss of enamel, atypical wear facets, Pulp may be exposed and many fractured teeth can also occur. Muscular: Tenderness of the jaw muscles on palpation, muscular fatigue on

waking up in the morning, hypertrophy of masseter.

TMJ : Pain, crepitation, clicking in joint, restriction of mandibular movements.

Associated Features : Headache

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Management
Adjunctive therapy
a. Psychotherapy b. Auto-suggestion and hypnosis c. Relaxing exercise and

Occlusal therapy
a. Occlusal adjustments

b. Bite plates and splints c. Occlusal reconstruction and

physiotherapy d. Elimination of oral pain and

prosthesis d. Bite guard Tranquilizers (a dose of 25 mg of hydroxyzine 1 hr before bed time).

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discomfort

Maxillary midline diastemas

Most common compliant Defined as a space greater than 0.5mm between the proximal surfaces of adjacent teeth Management: Removable appliances Fixed appliances

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Removable appliances
Active plate with finger springs

Split labial bow

Hawleys plate with an active labial bow

Fixed appliances:
Elastics Edgewise system with a simple looped partial arch wire made from a rectangular wire, tied under tension into both the brackets.
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Conclusion

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References
Orthodontics: current principles & practice Graber & Vanarsdall, 4th edition Contemporary orthodontics Proffitt, 3rd edition

Orthodontics principles & practice: T.M. Graber 3rd edition

Pediatric dentistry principles & practice: Muthu, Siva kumar Pediatric dentistry infancy through adolescence Pinkham, 3rd edition Textbook of pedodontics Shobha tandon, 2nd edition
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 Dewel B.F. Serial extraction in orthodontics. Indications, objectives and treatment procedures. Am. J. Orthod, 1954; 906-926. Dewel Serial extraction: Its limitation and contraindication in

orthodontic treatment. Am. J. Orthod, 1967; 53(12): 904-921.

Clinical pedodontics - Finn S.B. ,4th Edtion Jack G. Dale Serial extraction part I. JCO, 1976; 44-60. Jack G. Dale Serial extraction part II. JCO, 1976; 116-136. Jack G. Dale Serial extraction part III. JCO, 1976; 196-216.

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 Second molar extraction in the treatment of lower premolar crowding. British J. Orthod, 1992; 19: 299-304. Margaret E. Richardson et al Residual lower first premolar

extraction space. British J. Orthod, 1990; 17: 229-234.

Dentistry for child and adolescent Ralph E. Mc Donald 1993, 5th edition. Robert M.L. the effect of eruption guidance and serial extraction on the developing dentition. Pediatric Dentistry, 1987; 9(1): 65-70.

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References
Orthodontics Current Principles and Technique T.M.Graber. Hand Book of Orthodontics - Robert E Moyers Contemporary Orthodontics - Proffit WR Text Book of Orthodontics - G.Singh Essential of Preventive and Community Dentistry- Shoban Peter Text Book of Pedodontics Shoba Tandon.

Phase I Treatment initiated during the primary or mixed dentition with the purpose to prevent, intercept or correct an orthodontic problem, also known as, early treatment. Phase II Treatment initiated during the permanent dentition with a comprehensive approach to correcting the orthodontic problems, also known as, comprehensive treatment.

II. Specific Goals of Early Treatment Overall goal of early treatment: To improve or correct orthodontic problems that would result in: Irreversible damage to the dentition and supporting structures Progression into a more severe orthodontic problem that would be more difficult to treatment in Phase II.

 Preventive early treatment: Patient education and maintenance of a favorable orthodontic condition. e.g. patient education of stopping digit sucking habits, space maintenance appliances.

 Interceptive early treatment: Improvement of an orthodontic problem. e.g. Primary tooth guidance extractions, reduction of excessive overjet, growth modification appliances, space
redistribution, space creation, deep bite reduction, habit appliances.

 Corrective: Complete or nearly complete correction of an orthodontic problem. e.g. Expansion appliances, growth modification appliances, alignment of anterior teeth

Preventive procedures
Parental counseling
prenatal postnatal

Caries control Space maintenance Extraction of deciduous teeth Treatment of abnormal frenal attachments Treatment of locked permanent first molars Abnormal oral musculature related habits

 Corrective procedure:

SERIAL EXTRACTION CORRECTION OF DEVELOPING CROSS BITE CONTROL OF ABNORMAL HABITS SPACE REGAINING MUSCLE EXERCISES INTERCEPTION OF SKELETAL MALRALATION REMOVAL OF SOFT TISSUES OR BONY BARRIER TO ENABLE

ERUPTION OF TEETH

 MINOR PROCEDURES 1.EXTRACTIONS A.therapeutic extraction B.serial extraction C.extraction of caries teeth D.extraction of malformed teeth E.extraction of supernumerary teeth F.extraction of impacted teeth

2.surgical uncovering of teeth 3.Frenectomy 4.Precision 5.Transplantation of teeth 6.corticotomy MAJOR PROCEDURES 1.orthodontic surgeries 2.cosmetic surgeries 3.surgical corrections in cleft lip and cleft palate patients 4.surgical assisted rapid maxillary expansion